Immunization Education Update For Physicians and Staff Immunizations

Immunization Education Update For Physicians and Staff Immunizations

Immunization Education Update For Physicians and Staff Immunizations for Adolescents September 2017 Celebrating 16 years Presented By: Georgia Chapter - American Academy of Pediatrics Georgia Immunization Program In Cooperation with: Georgia Academy of Family Physicians Georgia Chapter American College of Physicians Georgia OB/Gyn Society

Faculty Disclosure Information In accordance with ACCME* Standards, all faculty members are required to disclose to the program audience any real or apparent conflict of interest to the content of their presentation. This presentation will include the most current ACIP recommendations for frequently used vaccines but is not a comprehensive review of all available vaccines. Some ACIP recommendations for the use of vaccines have not currently been approved by the FDA. Detailed information regarding all ACIP Recommendations is available at www.cdc.gov/vaccines/acip/recs/index.html *Accreditation Council for Continuing Medical Education Objectives At the end of this presentation, you will be able to:

Name four vaccines recommended for adolescents Explain the importance of preventing these diseases in adolescents Understand strategies practitioners can use to increase immunization rates in adolescents Address parental hesitation regarding HPV vaccine for young adolescents List at least 2 reliable sources for immunization information Advisory Committee on Immunization Practices (ACIP) 15 voting members with expertise in one or more of the following: Vaccinology Immunology

Infectious diseases Pediatrics Internal Medicine Preventive medicine Public health Consumer perspectives and/or social and community aspects of immunization programs ACIP develops recommendations and schedules for the use of licensed vaccines Four Vaccines Are Recommended for ALL Adolescents Tetanus-diphtheria-acellular pertussis vaccine (Tdap)

Influenza (flu) vaccine---every year Meningococcal conjugate vaccine (MCV4) Human papillomavirus vaccine (HPV) Estimated Vaccination Coverage Among Adolescents Aged 13 17 Years - 2016 10000% US

9000% Column1 8000% 7000% 6000% 5000% 8 7. 0 4000% 3000% 2000% 1000%

0% 1 Tdap 1 Men ACWY 1 HPV Female 1 HPV Male 3 HPV Female National Immunization Survey-Teen (NIS-Teen), United States, 2016. MMWR/August 25. 2017/ Vol.66/No. 33

3 HPV Male AAP Tetanus Diphtheria Pertussis Pertussis in Adolescents Prolonged cough (3 months or longer) Complications (pneumonia, rib fractures)

Hospitalization Missed school and work Impact on public health system Vomiting after prolonged coughing Weight loss Multiple medical visits and extensive medical evaluations Loss of sleep Transmission to infants

Ohio Chapter, American Academy of Pediatrics. TIES: Teen Education Immunization Sessions Why Do Adolescents Need Pertussis Vaccine? Pertussis is endemic in the United States Reported cases: in U.S. 2011: 18,719 179 in Georgia 2012: 48,277 318 in Georgia 2013: 28,639 317 in Georgia 2014: 32,118 407 in Georgia 2015: 20,762 - 244 in Georgia Protection provided by the DTaP vaccine series wanes, so adolescents need Tdap as a booster

Increasing Tdap immunization rates among adolescents is an important strategy for reducing pertussis among adolescents and infants too young to be fully immunized Summary of Notifiable Infectious Diseases http://www.cdc.gov/mmwr/mmwr_nd/index.html Diphtheria, Tetanus and Pertussis Vaccine for Adolescents ACIP recommends: One dose of Tdap: For children and adolescents starting at 11 or 12 years of age For all adults aged 19 years and older who have not had Tdap previously

There is no minimal interval between the last dose of Td and Tdap. 2017 Childhood Schedule: Children 7-10 years of age who receive Tdap as part of the catch-up series can be given Tdap again at ages 11-12 years MMWR, September 23, 2011, Vol 60, #37 MMWR, February 7, 2017, Vol. 66 MMWR, January 14, 2011, Vol 60, #01 MMWR, June 29, 2012 Vol 61, #25 Tdap for Pregnant Women ACIP recommends: One dose of Tdap during each pregnancy, irrespective of a prior history of receiving Tdap.

Optimal timing for Tdap administration is between 27 and 36 weeks gestation. ACIP guidance and current data suggest that vaccinating earlier in the 27 through 36 week window will maximize passive antibody transfer to the infant. If Tdap is not given during pregnancy, and has not been given previously, administer Tdap immediately postpartum. According to ACIP, Pregnant women and adolescents may receive additional doses of Tdap. Ref: Advisory Committee on Immunization Practices. Updated ACIP statement for pertussis, tetanus and diphtheria vaccines presented by Jennifer L. Liang, October 19, 2016. MMWR, February 7, 2017, Vol. 66 Influenza and Adolescents Flu spreads when infected people cough or sneeze. Flu can cause mild to severe illness, and in some cases it can cause death.

Most preteens and teens who get sick with the flu recover within a couple of weeks, some will get complications like sinus infections, or pneumonia. Preteens and teens who have chronic health problems like diabetes (type 1 and 2) or asthma, are at a greater risk for complications from the flu, but even healthy adolescents can get very sick from the flu. U.S. Department of Health and Human Services Centers for Disease Control and Prevention: Flu Vaccines for Preteens and Teens Influenza Vaccine Coverage 2015-16 Season Influenza vaccine coverage among children and adolescents 6 months through 17 years decreased with increasing age: U.S. Georgia 6-23 months 75.3%

2-4 years 66.8% 61.9% (6 mo. -4 years) 5-12 years 61.8% 50.7% 13-17 years 46.6% 43.2% Coverage rates remained basically the same for the 2016-2017 flu season. cdc.gov/flu/fluvaxview 2015-16 National Immunization Survey-Flu (NIS-Flu) and Behavioral Risk Factor Surveillance System (BRFSS) Accessed 10-4-17 FDA Recommended Influenza Antigens

for 2017-2018 Season in the U.S. Trivalent Vaccines (IIV3): A/Michigan/45/2015 (H1N1) (NEW) A/Hong Kong/4801/2014 (H3N2)-like virus B/Brisbane/60/2008-like virus Quadrivalent Vaccines (IIV4) also include: B/Phuket/3073/2013-like virus ACIP recommends annual influenza vaccine for all persons 6 months of age and older who do not have contraindications. Recommendations and Reports Vol. 66 / No. 2 MMWR / August 25, 2017 Influenza Vaccines for 2017-2018 Season 6 months

3 years 4 years Fluzone (IIV4) Fluarix (IIV4) Fluvirin (IIV3) 6-35 mos0.25 ml dose FluLaval (IIV4) 6 mos. and older---

Flucelvax (ccIIV4)* 5 years Afluria (IIV3) 18 years 65 years FluBlok (RIV3 & RIV4) ** Fluzone HighDose (IIV3)

Afluria (IIV4) Fluad (aIIV3) 0.5 ml dose Fluzone Intradermal (IIV4) Ages 18-64 yrs. *Cell-cultured **Recombinant Ref: Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD). https://www.cdc.gov/mmwr/volumes/66/rr/rr6602a1.htm

Live, Attenuated Influenza Vaccine (LAIV4) FluMist MedImmune (Nasal Spray) licensed for healthy persons 2 through 49 years of age ACIP recommendation Due to poor effectiveness in past 3 seasons and concerns regarding the effectiveness against A(H1N1) viruses: LAIV4 should not be used in the 2017-2018 season. Currently only IIV provides protection against influenza and should be used for all persons 6 months and older who do not have contraindications. MMWR 66(2); 1-24, August 25, 2017

Influenza Vaccination of Persons with a History of Egg Allergy Persons with a history of egg allergy who have had only hives after exposure to eggs should receive influenza vaccine. Persons who report having had reactions to eggs such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention may receive influenza vaccine. Vaccine should be administered in a medical setting supervised by a healthcare provider who is able to recognize and manage severe allergic conditions. A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of the vaccine. Recommendations and Reports Vol. 65 / No. 5 MMWR / August 26, 2016 Improve Access to Influenza Immunizations in Your Practice

Immunization only visits Walk-ins for immunizations Implement standing orders Early, extended, or weekend hours Mass vaccination clinics Journal of Adolescent Health, 54 (2014) 241-242 Meningococcal Disease (caused by Neisseria meningitidis) Meningitis ~50% of cases 9-10% fatality rate

Meningococcemia 5%-20% of cases Up to 40% fatality rate Rash Vascular damage Disseminated intravascular coagulation Multi-organ failure Shock Death can occur in 24 hours Photo courtesy CDC: Dr. Brodsky & Mr. Gust 11-19% of survivors have permanent sequelae Ref: 1. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th Edition, 2015. 2. AAP Red Book 2015

Meningococcal Disease: Adolescents and Young Adults Are Most at Risk Age-specific Fatalities, US, 1999-20101-12 Number of Deaths 500 374 400 300 200 177 177

157 147 141 176 100 110 85 86

62 0 <1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 Age Group (years) 85+ Neisseria meningitidis Risk Factors for Invasive Disease

Immunodeficient persons (e.g., no spleen) HIV infection Family members of an infected person Smoking

Passive exposure to smoke Upper respiratory tract infection Crowding College students (living in dormitories) Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book), 13th Edition, (2015)

Vulnerability of Adolescents and Young Adults to Meningococcal Disease Spread through respiratory and throat secretions Coughing, sneezing Kissing Sharing eating utensils, water bottles, etc. Crowded settings facilitate transmission College dormitory Crowded household Military barracks Nightclubs, bars Give2MCV4 project: www.Give2MCV4.org Meningococcal Vaccines Recommended for Adolescents and Young Adults in the U.S. Year first licensed

Quadrivalent meningococcal conjugate (MCV4) 2005 2014 Serogroup(s) A, C, W, Y B Recommendations Recommended for routine use in adolescents

Give2MCV4 project: www.Give2MCV4.org Meningococcal B (MenB) Recommended, based on individual clinical decision making, for adolescents and young adults 1623 years of age Meningococcal Conjugate Vaccine (MCV4) (Men A,C,Y, W-135) Menactra licensed for 9 mos. through 55 years Menveo licensed for ages 2 mos. through 55 years

ACIP recommends: First dose at age 11 or 12 years and a booster dose at 16 years. If first dose is at 13-15 years, give booster dose 5 years after the first dose or sooner, but after age 16 if entering college or technical school. If first dose is received 16 years of age, a 2nd dose is not needed. Persons aged 21 years or younger attending school or college should have documentation of one dose of MVC4 not more than 5 years before enrollment. Why Boost at 16 Years of Age? Studies indicate that protective levels of circulating antibody decline 3 to 5 years after a single MCV4 dose. Vaccine effectiveness casecontrol study suggests that many adolescents are not protected 5 years after vaccination. According to ACIP a single dose of meningococcal conjugate

vaccine administered at age 11 or 12 years is unlikely to protect most adolescents through the period of increased risk at ages 16 through 21 years. Meningococcal Conjugate Vaccine (MCV4) For Adolescents with Certain Medical Conditions Two-dose primary series in adolescents with HIV infection Asplenia Complement component deficiency Minimal interval of 8 weeks between Dose 1 and 2 Persons Who Have Persistent Complement Component

Deficiencies (C3, C5-9, Properdin, Factor D, and Factor H) and Anatomic or Functional Asplenia should receive a booster dose every 5 years. MMWR / March 22, 2013 / Vol. 62 / No. 2 Serogroup B Meningococcal Vaccine Bexsero licensed for ages 10 through 25 years (2 dose) Trumenba licensed for ages 10 through 25 years (2 dose & 3 dose) The 2 vaccine products are not interchangeable (Category B Permissive recommendation)# A Men B vaccine series may be administered to adolescents and young adults 16 through 23 years of age to provide short-term protection against most strains of Men B. Preferred age is 16-18 years. #

MMWR; October 23, 2015, Vol .64 #41; 1171-1176 Serogroup B Meningococcal Vaccine ACIP recommends serogroup B meningococcal vaccine for: Persons with persistent complement component deficiencies Persons with anatomic or functional asplenia Microbiologists routinely exposed to isolates of Neisseria meningitidis Persons identified to be at increased risk because of a serogroup B meningococcal disease outbreak MMWR; June 12, 2015 ,Vol. 64 #22; 608-611 Serogroup B Meningococcal Vaccine Administration Bexsero licensed for ages 10 through 25 years (2 dose)

Trumenba licensed for ages 10 through 25 years (2 dose or 3 dose) MenB-FHbp (Trumenba) 2 dose schedule administered at 0, 6 months Given to healthy adolescents who are not at increased risk for meningococcal disease 3 dose schedule administered at 0, 1-2, 6 months Given to persons at increased risk for meningococcal disease and for use during serogroup B outbreaks MenB-4C (Bexsero) 2 dose schedule 0, 1-2 months Meningitis B Vaccine Since licensed and designated a permissive recommendation for healthy adolescents and adults, some colleges and universities have added this vaccine to their list of optional vaccines. Families may inquire about this vaccine.

KEY POINTS It is not a replacement for the meningococcal conjugate vaccine. Insurance coverage has improved since the permissive designation and most plans that cover vaccines will cover this one. Consider discussing with your vaccine representative about purchasing requirements (ex. number of doses to be purchased). Meningococcal Vaccine Updates The following vaccines have been discontinued: MENHIBRIX (Men C&Y + Hib) licensed for ages 6 weeks through 18 months MENOMUNE (A/C/Y/W-135) licensed for use in persons 2 years of age and older. Types of Human Papilloma Virus (HPV) (More Than 150 Types Identified)

Mucosal/Genital ~40 types High risk types 16, 18, 31, 33, 45, 52, 58 (and others) Cervical cancer Anogenital cancer Oropharyngeal Cancer Cancer precursors Low grade cervical disease Cutaneous Low risk types 6, 11 and others

Genital Warts Laryngeal Papillomas Low grade cervical disease Skin warts Hands and Feet Ref: 1. Epidemiology and Prevention of Vaccine Preventable Diseases 13 th Edition, 2015 2. Red Book AAP 2015 Report of the Committee on Infectious Diseases 3. MMWR, August 29, 2014, RR Vol. 63, No. 5 HPV Vaccines Gardasil 9 (9vHPV) HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58 (CERVARIX & GARDASIL 4 are no longer available in the U.S. as of December, 2016)

ACIP recommends HPV vaccine starting at age 11 or 12 years for: All females through 26 years of age All males through 21 years of age Men 22 through 26 years who have sex with men or have an immunocompromising condition. All other males 22 through 26 years. Series can be completed with 9vHPV if started with 2v or 4v. MMWR, March 27, 2015, Vo1 64, No. 11 MMWR, December 16, 2016, Vol 65, No. 49 ACIP Recommendations and Schedule 2 Dose Schedule: HPV vaccine initiated between 9-14 years can be given in two doses: 0, 6-12 months. (If the 2nd dose is administered at least 5 months after 1 st dose, it can be

counted). 3 Dose Schedule: HPV vaccine initiated after the 15th birthday or certain immunocompromising conditions should be vaccinated with the 3 dose schedule: 0, 1-2, 6 months (Dose 2 should be given at least 1 to 2 months after first dose (1 month minimum); Dose 3 should be given at least 6 months after the first dose (minimum of 3 months between dose 2 and 3) Reference: 2017 Supplement to Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition (the Pink Book) Evidence of Reduction in HPV Prevalence National Health and Nutrition Examination Survey (NHANES) Data Prevalence of HPV 6,11,16,18 in U.S. girls age 14-19

2003-2006: 11.5% HPV Vaccine Licensed in 2006 2007-2010: 5.1% Markowitz et al J Infectious Dis. 2013: 208: 385 Ohio Chapter, American Academy of Pediatrics. TIES: Teen Education Immunization Sessions Markowitz, L. MD. Division of Viral Diseases. ACIP, June, 23,2016. Top 5 reasons for not vaccinating daughter, among parents with no intention to vaccinate their child against HPV Not sexually active

Lack of knowledge Safety concerns/side effects Not recommended by provider Not needed or necessary** 0 5 10 15 20 Percent ** Did not know much about HPV or HPV vaccine.

CDC. Human papillomavirus vaccination coverage among adolescents, 2007-2013. Postlicensure vaccine safety monitoring, 2006-2014-U.S. 25 Reasons to Immunize Against HPV at 11-12 Years of Age Higher antibody level attained when given to pre-teens rather than to older adolescents or women At this age, more likely to be administered before onset of sexual activity HPV can be transmitted by other skin-to-skin contact, not just sexual intercourse There is no link between vaccine and riskier sexual behavior Even those who abstain from sex until marriage can be infected by their marital partner Individuals need all three doses for full protection

This is an anti-cancer vaccine Presentation by Anne Schuchat, MD, RADM US Public Health Service, Assistant Surgeon General, Director National Center for Immunization and Respiratory Diseases at Immunize Georgia Conference, Atlanta, GA September 11, 2014 Gable, J.,Eder, J., Noonan, K. and Feemstar, K. Increasing HPV Vaccination Rates Among Adolescents: Challenges and Opportunities. PolicyLab: The Childrens Hospital of Philadelphia, 2016. HPV Vaccine: Special Situations Vaccine can still be given, even if History of genital warts History of abnormal Pap test result Patient is immunocompromised Female patient is breastfeeding Ohio Chapter, American Academy of Pediatrics. TIES: Teen Education Immunization Sessions Types of Vaccine-Hesitant Parents

Uninformed but educable Want education to counter anti-vaccine information Misinformed but correctable Need information about vaccine benefits Well-read and open-minded Want to intelligently discuss pros and cons

Strongly vaccine-hesitant Willing to listen but not likely to change their mind right away Strong-willed and committed against vaccines Want to sway the health care provider to their line of thinking References: 1. Halperin SA. Canadian J CME. 2000;12(1):62-74. 2. Harrington JW. Consultant Ped. 2011;10(11):S17-S21. Talking with Parents about Vaccines Use language and examples parents can understand Give written information (VIS) prior to the immunization visit so parent can review benefits and risks Draw upon your experiences as a health care provider Solicit and welcome questions

Recognize that some parents may be more interested in discussing vaccines than others Immunization education should include: Benefits of and risks associated with the vaccines After care instructions for managing side effects Adapted from Glen Nowak, PhD. CDC Addressing Parents Top Questions about HPV Vaccine Why does my child need the HPV vaccine? HPV Vaccine is important because it prevents cancer. This is why I recommend that your son/daughter be vaccinated today. What diseases are caused by HPV?

Certain HPV types can cause cancer of the cervix, vagina, and vulva in females, cancer of the penis in men, and in both females and males, cancers of the anus and the throat. We can help prevent infection starting the HPV vaccine series for your child today. Is my child really at risk for HPV? HPV is a very common and widespread virus that infects both females and males. We can help protect your child from the cancers and diseases caused by the virus by starting HPV vaccination today. HPV vaccination works best at the recommended ages of 11 or 12 years.

Why do they need HPV vaccine at such a young age? Why do boys need HPV vaccine? HPV infection can cause cancers of the penis, anus, and throat in men and it can also cause genital warts. HPV vaccine can help prevent the infection that lead to these diseases. Adolescent Vaccine Safety Faintingor syncopecan occur after any medical procedure, including vaccination

Adolescents should be seated or lying down during vaccination Providers should consider observing patients in seated or lying positions for 15 minutes after vaccination Concern: risk for serious secondary injuries Examples of Effective Messaging For Providers CDC Research shows: The HPV vaccination is cancer prevention message resonates strongly with parents. Studies show that a strong provider recommendation is the best predictor of vaccination. Sample Dialogue: HPV vaccination is very important because it prevents cancer. I want your child to be protected. That is why I am recommending that your son/daughter receive their first HPV vaccine today.

Examples of Effective Messaging For Providers CDC Research Shows: Providers who emphasize their personal belief in the importance of HPV vaccines help parents feel secure in their decision. Sample Dialogue: I strongly believe in the importance of this cancer-preventing vaccine. My son/daughter has received it. Experts agree that this vaccine is very important for your child. Improve HPV Immunization Rates in Your Practice RECOMMEND HPV Vaccine along with Tdap and meningococcal vaccine Stress Cancer Prevention Give Vaccine Prior to Potential Exposure to the Virus Address Safety Concerns

Text, phone and/or Email patient/family as a reminder to complete HPV series Remember this is part of routine adolescent care Allow shots to be given to adolescents with minor illnesses like colds, diarrhea or low-grade fever Allow patients to come in for an immunization-only visit Critical Elements for Immunization Services Celebrating 16 years Recommended Healthcare Personnel Vaccinations Hepatitis B Influenza

Measles, Mumps, Rubella (MMR) Varicella (Chickenpox) Tetanus, Diphtheria, Pertussis (Tdap) Meningococcal (recommended for microbiologists who are routinely exposed to isolates of N. meningitidis). Are YOU up to date? Available at www.immunize.org, P#2017 PRE-EXPOSURE EVALUATION FOR HEALTH-CARE PERSONNEL PREVIOUSLY VACCINATED WITH COMPLETE, 3-DOSES OF HEP B VACCINE SERIES WHO HAVE NOT HAD POSTVACCINATION SEROLOGIC TESTING Measure antibody to hepatitis B surface antigen (anti-HBs) anti-HBs 10 mIU/mL

Below adequate level anti-HBs 10mIU/mL 1 dose of HepB vaccine, 4-6 wks.--- serologic testing Below adequate level At or above adequate level 2 more doses of HepB vaccine, 4-6 wks.--- serologic testing

Below adequate level At or above adequate level HCP need to receive hepatitis B evaluation for all exposures No Action for Hepatitis B prophylaxis (regardless of source patient hepatitis B surface antigen status)

Vaccinated HCP whose antiHBs remains <10 mIU/mL after revaccination (i.e., after receiving a total of 6 doses) should be tested for HBsAg and anti-HBc to determine infection status. MMWR, December 20, 2013, Vol 62. RR # 10 2017 Immunization Schedules All staff must use the same immunization schedule Five Schedules: Children & Adolescent 0 through 18 years Children & Adolescent based on medical indications Catch-up schedule for

ages 4 months -18 years Adult 19 years and older Adult based on medical and other indications READ THE FOOTNOTES http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html http://www.cdc.gov/vaccines/schedules/hcp/adult.html MMWR, February 7, 2017, Vol. 66 Indications Recommendations Requirements Indication Information about the appropriate use of the vaccine Recommendation ACIP statement that broadens and further delineates the

Indication found in the package insert Basis for standards for best practice Requirement Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school Updated Vaccine Storage and Handling Recommendations Use stand-alone refrigerator and stand-alone freezer units. If combined, use only refrigerator part. Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit. Use a bio-safe glycol-encased probe or a similar temperature buffered probe. Use digital data loggers. Do not store ANYTHING ELSE in refrigerator.

Review vaccine expiration dates and rotate vaccine stock weekly. *Data loggers will be required for VFC January 2018* Ref: Vaccine Storage and Handling Toolkit, June 2016 Maintaining Appropriate Vaccine Storage & Handling Assign a primary and alternate vaccine coordinator. Store all vaccines as recommended by manufacturer and IN ORIGINAL PACKAGING. Monitor and record temperatures of refrigerator and freezer twice daily. Maintain temperature log records for 3 years. Take immediate action for all out-of-range temps.

Implement a vaccine emergency system. If it is necessary to transport vaccine, do NOT use dry ice. Ref: Vaccine Storage and Handling Toolkit, June, 2016 Check Expiration Date of Vaccines and Diluents Vaccine Expiration Date is 12/17 Use through December 31, 2017 Do NOT use on or after January 1, 2018. 12/17 12/10/17 Vaccine Expiration Date is 12/10/17 Use through December 10, 2017

Do NOT use on or after December 11, 2017. Note: Some multidose vials have a specified time frame for use once the vial is entered with a needle. This may vary from the expiration date printed on the vial. General Best Practice Guidelines for Immunization (formerly General Recommendations on Immunization) Timing and Spacing Contraindications and Precautions NEW Prevention and Management of Adverse Reactions Vaccine Administration Storage and Handling of Immunobiologics Altered Immunocompetence

Special Situations Vaccination Records Vaccination Programs Vaccine Information Sources Kroger AT, Duchin J, Vzquez M. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). [www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf]. The 7 Rights of Vaccine Administration Right Patient Right Vaccine or Diluent Right Time* Right Dosage Right Route, Needle Length, Technique Right Site for route indicated Right Documentation * Correct age, appropriate interval, and administer before vaccine or diluent expires

Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th Edition, 2015. Sites for Vaccine Administration Intramuscular (IM) DTaP, Tdap, Hib, Td, Hep A, Hep B, PCV13, IIV, MCV4, HPV Subcutaneous (SQ, SC, or sub-Q) MMR, MMRV, Varicella, MPSV4, Herpes Zoster Either intramuscular or subcutaneous IPV, PPSV23 Intranasal LAIV Intradermal IIV3, IIV4 (Fluzone) Orally (PO) Rotavirus

Always Document Accept only written documentation of prior immunizations Provide VIS prior to administration of vaccine After vaccine administration, document: Publication date of VIS & date VIS given Date, site, route, antigen(s), manufacturer, lot # Person administering vaccine, practice name and address Vaccine refusals with a signed Refusal to Vaccinate Form GA law does not require signed consent for immunizations A Birth to Death Immunization Registry Providers administering vaccines in Georgia must provide appropriate information to GRITS. GRITS personnel can work with your EHR/EMR vendor to create an interface between your system and GRITS that will drastically decrease data entry time for your practice. Contact the GRITS Training Coordinator at (404) 463-0807 or e-mail : [email protected]

Exemptions From School Medical Exemption O.C.G.A. 20-2-771(d) Used when a physical disability or medical condition contraindicates a particular vaccine. Requires an annual review. The medical exemption is documented in GRITS. Religious Exemption O.C.G.A. 20-2-771(e) Parent or guardian must be directed to http://dph.georgia.gov/immunization-section to obtain an Affidavit of Religious Objection to Immunization form. This form must be signed and notarized and provided to the school. Must be kept on file at school/facility in lieu of an immunization certificate. Affidavit does not expire. Georgia does not have a philosophical exemption

Monitoring Vaccine Safety VAERS NEW Option 1 - Report Online to VAERS (Preferred) Submit a VAERS report online. The report must be completed online and submitted in one sitting and cannot be saved and returned to at a later time. Your information will be erased if you are inactive for 20 minutes; you will receive a warning after 15 minutes. Option 2 - Report using a Writable PDF Form Download the Writable PDF Form to a computer. Complete the VAERS report offline if you do not have time to complete it all at once. Return to this page to upload the completed Writable PDF

form by clicking here. If you need further assistance with reporting to VAERS, please email [email protected] or call 1-800-822-7967. FDA and Vaccine Data Link Safety Project VERP: VACCINE ERROR REPORTING SYSTEM On line reporting at http://verp.ismp.org/ Report even if no adverse events associated with incident Will help identify sources of errors to help develop prevention strategies Why do we miss opportunities to

immunize? Physician or patient unaware of the need Visits for mild illness, injury, or follow-up Need for multiple vaccines Invalid contraindications Inappropriate clinic policies Reimbursement deficiencies Invalid Contraindications to Vaccine Mild illness or injury

Antibiotic therapy Disease exposure or convalescence Pregnancy or immunosuppression in household Family history of an adverse event to a vaccine Breastfeeding Prematurity Allergies to products not in vaccine Need for TB skin testing

Need for multiple vaccines Ref: General Recommendations on Immunization - MMWR January 28, 2011, Vol 60 # RR02) Vaccine Risk Perception Many parents are not familiar with vaccine-preventable diseases and perceive the risks of vaccines outweigh the benefits. Concerns Immune system overload

Children get too many shots at one visit Vaccines have side effects (adverse reactions) Immunity from the disease is better than immunity from a vaccine (i.e. chicken pox) Vaccines cause autism Response to Vaccine Safety Concerns Vaccines are among the most thoroughly tested and safest things we put into our bodies Refusing a vaccine means taking the risks of the disease and of spreading the disease to others Natural immunity (from disease) may come with complications, permanent damage, or death In Georgia, an unimmunized student may be prohibited from attending school during an epidemic* Consistent reproducible research has shown that autism is NOT caused by:

Thimerosal Multiple vaccines at one time MMR vaccine * State of Georgia -Rules of Department of Human Services: Public Health 290-5-4-.07 Anti-Vaccine Movement Promotes the idea that there is less evidence of disease today and immunizations are no longer needed Sends confusing & conflicting information Uses stories, personal statements, and books to play on the emotional side of concerned parents Encourage parents/patients to: Get the facts Consider the source Discuss their concerns with you Resources for Factual & Responsible Vaccine

Information Be sure everyone in the office understands the mission Human stories often influence people more than statistics To understand the human stories behind HPV, listen to survivors Shot By Shot Unprotected People on www.immunize.org Presentation by Jill Roark and Allison Fisher Health Communication Science Office, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention from GA AAP Webinar, Atlanta, GA March 16, 2016.

Important Office Practices Use reminders on medical records and notify patients when vaccines are needed Use of automatic text-messaging systems to remind patients of needed or scheduled appointments Recall patients when vaccine is available after a shortage 1 Assess your immunization rates using CoCASA to improve 2 patient care, HEDIS scores, and identify problem areas Use current codes for vaccines and vaccine administration 1. Comprehensive Clinic Assessment Software Application 2. Health Plan Employer Data and Information Set Stay Current! Sign up for listserv sites which provide timely

information pertinent to your practice www.immunize.org/resources/emailnews.asp AAP Newsletter CDC immunization websites (32 in all) CHOP Parents Pack Newsletter IAC Express, Needle Tips and Vaccinate Adults Websites specific to particular vaccines Improve Access to Immunizations in Your Practice Immunization only visits Walk-ins for immunizations Implement standing orders Early, extended, or weekend hours Mass vaccination clinics NEW

High Immunization rates begin with a team designed plan! Questions? Check out these links for more immunization information and resources! National Immunization Program E-mail [email protected] Hotline 800.CDC.INFO Website http://www.cdc.gov/vaccines Georgia Immunization Program E-mail [email protected] Hotline

404-657-3158 Website http://dph.georgia.gov/immunization-section Immunization Action Coalition E-mail [email protected] Phone 651.647.9009 Website www.immunize.org Test Your Knowledge! EPIC 2017 Test Your Knowledge! Emily is 12 years old and comes to your office for a physical exam. Her immunizations were up-to-date when

she started kindergarten. What vaccines do you recommend for her? Test Your Knowledge! Emily is 12 years old and comes to your office for a physical exam. Her immunizations were up-to-date when she started kindergarten. What vaccines do you recommend for her? Tdap, Meningococcal Conjugate, HPV, possibly a 2nd varicella, hepatitis A Influenza vaccine (in the fall) Ref: Child and Adolescent Immunization Schedule Test Your Knowledge! Simon received MPSV4 at 5 years of age for international travel and a dose of MCV4 at age 11.

Does he need a booster dose of MCV4 vaccine at age 16? Test Your Knowledge! Simon received MPSV4 at 5 years of age for international travel and a dose of MCV4 at age 11. Does he need a booster dose of MCV4 vaccine at age 16? Yes. Any meningococcal vaccination given prior to the tenth birthday (either with MCV4 or MPSV4) does NOT count toward routinely recommended doses. IAC Ask the Experts - Reviewed September 2013 Test Your Knowledge! Ethan is 17 years old. After his second DTP vaccine at 4 months of age he cried persistently for 4 hours, had a fever of 104F, and developed a severe local reaction at the injection site.

His pediatrician subsequently administered DT at 6 months, 18 months and 5 years of age. He received Td when he was 12 years old. With this history of a severe reaction to pertussis vaccine, should he receive Tdap? Test Your Knowledge! Ethan is 17 years old. After his second DTP vaccine at 4 months of age he cried persistently for 4 hours, had a fever of 104F, and developed a severe local reaction at the injection site. His pediatrician subsequently administered DT at 6 months, 18 months and 5 years of age. He received Td when he was 12 years old. With this history of a severe reaction to pertussis vaccine, should he receive Tdap? Yes, administer Tdap. These adverse reactions in infancy are

not contraindications or precautions for Tdap vaccination in adolescents. Ref: Preventing Tetanus, Diphtheria, and Pertussis Among Adolescents: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines MMWR Recommendations and Reports March 24, 2006 / Vol. 55 / No. RR-3 Test Your Knowledge! Dakota is an 18 year girl who will be starting her first year of college in August. She had her first dose of HPV vaccine on April 5 and her second dose on May 8. She will not be coming home again until late November. Should you give her the third dose of HPV vaccine before she leaves home in mid August? Test Your Knowledge! Dakota is an 18 year girl who will be starting her first year of college in August. She had her first dose of HPV

vaccine on April 5 and her second dose on May 8. She will not be coming home again until late November. Should you give her the third dose of HPV vaccine before she leaves home in mid August? No! The minimum interval between the second and third doses of vaccine is 12 weeks. The minimum interval between the first and third doses is 24 weeks. Ref: Immunization Action Coalition Ask the Experts April 2012 Test Your Knowledge! If dose #1 of HPV vaccine was given before the 15th birthday and it has been more than a year since that dose was given, would the series be complete with just one additional dose? Recommendation?

Test Your Knowledge! If dose #1 of HPV vaccine was given before the 15th birthday and it has been more than a year since that dose was given, would the series be complete with just one additional dose? Recommendation? Yes. Adolescents and adults who started the HPV vaccine series prior to the 15th birthday and who are not immunocompromised are considered to be adequately vaccinated with just one additional dose of HPV vaccine. Immunization Action Coalition Ask the Experts, #1283, January 2017 Test Your Knowledge! Which individuals are recommended to be vaccinated against meningococcal serogroup B disease who are not in risk groups? Recommendation?

Test Your Knowledge! Which individuals are recommended to be vaccinated against meningococcal serogroup B disease who are not in risk groups? Recommendation? ACIP recommends that a MenB vaccine series (Bexero, MenB-4C, GSK; Trumenba, MenB-FHbp, Pfizer) may be administered to people 16 through 23 years of age with a preferred age of vaccination of 16 through 18 years. This Category B recommendation gives clinicians an opportunity to discuss the value of MenB vaccination with their patients and to make a decision together about the individuals need or desire for the vaccine based on risks, benefits, and wish for protection from the disease. Immunization Action Coalition Ask the Experts, #1283, January 2017

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